Endoleak mimic on CT angiography following endograft repair of abdominal aortic aneurysms with Endologix stent-grafts

Retrospective Review of Billowing Phenomenon-A Mimic of Endoleak Following Placement of Endologix Covered Stent for the Treatment of Abdominal Aortic Aneurysm

BACKGROUND

Billowing is a unique computed tomography (CT) finding of the Endologix stent graft where a rim of contrast is observed outside the stent's endoskeleton but still contained within the graft cover. The purpose of this study is to evaluate the incidence and clinical outcome of billowing following an Endologix stent-graft placement.

METHODS

All patients who underwent abdominal aortic aneurysm (AAA) repair with endovascular placement of an Endologix stent graft from January 2002 to September 2013 and who were followed with imaging were included in the study. The images were evaluated for the incidence of billowing. Demographics and clinical outcomes were also analyzed.

RESULTS

One hundred twenty-two patients received an Endologix stent graft for AAA repair at our institution. One hundred patients qualified for this study. Eighty-four patients had billowing with the majority (70 patients) having crescentic billowing, and the remaining 14 patients having focal outpouching. Average billowing thickness measured 4.2 mm (range 1-13). Sixty-three patients with billowing had multiple follow-up CT angiograms to allow serial monitoring. Twelve patients had resolution of billowing, 11 patients had reduction in billowing size, 14 patients had no change in billowing size, and 26 patients had increase in billowing size. Patients with billowing had a statistically significant reduction in aneurysm sac size in anteroposterior and transverse dimensions (P = 0.014 and 0.009, respectively). Five cases of billowing were misdiagnosed as endoleak. Nineteen true endoleaks were identified, of which 13 cases were associated with billowing.

CONCLUSIONS

Billowing does not seem to be associated with increased morbidity, mortality, increase in aneurysm size, or presence of endoleak. Billowing should be recognized as a common and benign finding of the Endologix stent.

Billowing of Endologix Powerlink Stent Graft in Post Endovascular Repair of Abdominal Aortic Aneurysm: Simultaneous Findings on CT and Ultrasound Imaging

Endoleaks remain a main concern in endovascular aneurysm repair. A potential false positive in the diagnosis of endoleak surveillance includes "billowing," a phenomenon of the polytetrafluoroethylene plastic outer fabric of the stent graft is seen separated from the struts of the metallic endoskeleton. Contrast presents beyond the endoskeleton but is still contained within the graft. This is secondary to intermittent attachment of the graft to the endoskeleton, and is only found in the Endologix Powerlink. The finding of billowing has been previously reported and is a common knowledge by those who deploy the stent graft. We report a case where there is contemporaneous imaging on computed tomography angiography as well as on ultrasound.

Billowing Of Endologix Powerlink Stent Mimicking Endoleaks

INTRODUCTION

Endoleaks remains one of the primary concerns of endovascular aortic aneurysm repair (EVAR) and is routinely followed with CT angiography (CTA). However, certain imaging findings can mimic endoleaks.

CASE PRESENTATION

A 65-year-old woman who had endovascular aortic repair (EVAR) of an abdominal aortic aneurysm with Endologix Powerlink system developed marked new circumferential cauliflower-like bulging of contrast-filled sacs at mid-stent-graft with enlargement of the excluded aneurysm at 3-year follow-up.

CONCLUSIONS

Considering the unique construct of the Powerlink stents, this is thought to represent aneurysmal degeneration of the outer fabric material from the metal struts and may potentially pressurize the excluded sac with risk for rupture.

Ultrasonographic Surveillance of Abdominal Aortic Endovascular Aneurysm Stent Graft Repair in a Dedicated Vascular Laboratory

Surveillance following abdominal aortic endovascular aneurysm repair (EVAR) is imperative to confirm graft patency, analyze residual sac size (RSS), and evaluate for complications. This retrospective study evaluated ultrasonographic (US) surveillance after EVAR compared to computed tomography (CT). US was done by 1 of 11 experienced registered technologists. US was ordered for surveillance more frequently than CT, with a ratio of 4:1. Compared to CT, US endoleak evaluations were 74% sensitive and 76% specific with a 63% positive predictive value and 84% negative predictive value. However, 11 CT scans were likely false negatives, and 1 CT was a false positive. For true positives that stated endoleak type, there was a 93% agreement between the type on US and CT. US had a 75% accuracy for RSS (95% CI, −1.02 to 1.16). These data support the use of US along with clinical symptoms as a first-line surveillance program after EVAR and are widely applicable to the majority of vascular laboratories that employ multiple registered vascular technologists. The adaptation of increased US surveillance would decrease the number of CT scans, thereby significantly reducing cost and radiation/contrast exposure to patients.